Hospital closures have been a dominant cultural trope of the National Health Service (NHS) for decades, and a keystone of public engagement with the British health system. Governmental and managerial frustration with public attachment to local facilities is well documented through the decades since it was first expressed in the debates around Powell’s Hospital Plan.¹ Photogenic images of stern-faced protesters and witty or emotive placards are the foundational building blocks of the topic in our cultural imagination. And the local political passions stirred up by potential closures stand out against other issues which escalate to the national stage. Perhaps the totemic signifier of the orientating role of hospital closures in British health politics is in the victories of single-issue ‘save our hospital’ candidates in elections to three UK parliaments: Dr Richard Taylor at Westminster, Dr Kieran Deeny at Stormont, and Dr Jean Turner at Holyrood.

While since the 1970s there have been possibilities for invited public involvement in the NHS,² few issues consistently provoke sufficient public concern to prompt significant uninvited participation. Simply put, resistance to hospital closures matters. And yet it is has only rarely been directly explored in empirical research.³ A series of influential medical geography papers have analysed discourses regarding threatened hospitals within media coverage of a handful of high-profile English closures. Moon and Brown’s discourse analysis of resistance to the proposed closure of St Bartholomew’s Hospital in London in the early 1990s is clear about the authorship of the documents analysed: ‘The discourses that we examine were largely produced and articulated from within the hospital itself or from the media.’⁴ However, later in the paper, one discourse is described, but not explained, as being driven by ‘the public’. Joseph, Kearns, and Moon argue that their use of media analysis offers advantages when compared with retrospective interviewing: ‘An important characteristic of this narrative is that it represents the views of actors as expressed at the time rather than through the hazy lens of recollection.’⁵ The ‘on the spot’ nature of a media report clearly brings advantages in terms of eliminating recall bias, but it is notable (and rarely acknowledged in these studies) that the filter of media reports and/or campaign group and official publications will also influence the range of actors represented and the nature of the views shared.

Where empirical research on members of the UK responding to hospital closures has taken place, understanding their perspectives is rarely the focus. Much contemporary scholarship has departed from, and thus perpetuated, a policy-driven account of public responses to hospital closures. Sometimes the inclusion of one or two public interviewees within a wider cohort of staff interviews simply adds weight to staff perceptions of public views.⁶ The use of discrete choice experiments, where public interviewees are funnelled into organisationally defined trade-offs (e.g. between patient safety and travel time to hospitals),⁷ and their responses to these dilemmas measured, epitomises the analytic dilemmas of a policy-framed approach. This approach lacks sensitivity to context and openness to exploring research participants’ own sense-making.⁸ As others have concluded, the top-down focus of most studies means that we know relatively little, in academic terms, about public opposition to hospital closures in the NHS.⁹

Drawing on the lessons of wider sociological literature on health activism, in this chapter we discuss qualitative interviews with campaigners in England, Scotland, Wales, and Northern Ireland to explore everyday practices of activism in response to hospital change and closure. Our account contributes to understandings of the NHS as graspable not only through policy documents, ministerial statements, and official records, but as a cultural entity constituted and reconstituted through the everyday expectations, interactions, and labour of the people who use and staff it. While not a historical study, this account of the NHS resonates with Handley, McWilliam, and Noakes’s description of cultural history as ‘a visible, living presence, able to command high passions among those who seek to make their version of the past a part of the dominant political narrative’.¹⁰ Qualitative interviews and oral histories (as used by Whitecross in this volume) can make a valuable addition to cultural histories of the NHS. We argue that threats to hospitals, understood as both material and symbolic NHS objects, create a moment of explicit contestation about the contemporary nature and value of the NHS in which we can discern wider lessons.

Health activism

As well as empirically neglecting public responses to hospital change and closure, studies of healthcare change have often neglected the insights of a well-established body of work on health activism. The latter half of the twentieth century witnessed a resurgence in ‘new’ social and political movements, spurring a renewed sociology into such phenomena.¹¹ The now classic early works of Tilly, Tarrow, and McAdam promoted strongly structural accounts of political opportunity, ‘rationally’ conceived and contentiously laboured, whereby interests of one group were secured at the expense of another. Such accounts, while influential, were later argued to have neglected the richness, complexity, and cultural embeddedness of social movements. Historical accounts have played a vital role in redressing this balance, tracing the development of post-war activism in its social and cultural contexts.¹²

Sociologists’ interest in health activism specifically, or ‘health social movements’, was piqued from the late 1990s, located against a backdrop of increasingly mobilised and organised ‘publics’ in industrialised countries. UK health movements continued to proliferate, to broaden in scope and ambition, and to leverage more resource and capacity in the effective pursuit of their aims.¹³ The early 2000s duly witnessed a number of key contributions to the sociology of health social movements, bringing established insights from social movement theory to bear on health activism (and vice versa).¹⁴

Central to such analyses are the epistemic dimensions of health activism, following Epstein’s ground-breaking work on the HIV/AIDS activist movement in the US.¹⁵ Epstein detailed the efforts of activists to ‘assert and assess credible knowledge about AIDS’ in innovative and productive ways,¹⁶ ultimately shaping the trajectory of medical science on the disease. At its extreme, public health activism poses a fundamental challenge to established biomedical authority and expertise,¹⁷ through the generation and credentialing of its ‘own scientific knowledge’.¹⁸ Typically, this involves a broadening of what constitutes credible evidence to include experiential and lay forms of knowledge as part of the growing ‘public shaping of science’.¹⁹ These alternative, at times subversive, renderings of knowledge are most stark where illnesses are ‘contested’,²⁰ with causes unknown or disputed evidence bases, or where illnesses have been overlooked because of broader structural inequalities.

In general, however, this literature demonstrates that health activists are not solely adversarial but work pragmatically to interweave experiential knowledge with more conventionally credentialed forms.²¹ For Epstein, movements do not reject science but seek ‘to transform it’ from the inside,²² versing themselves in scientific and medical discourses. Brown et al. describe a ‘continuum’ as a means to differentiate different organisations,²³ but they later concede that all health social movements assume ‘hybridity’ as they negotiate and reconcile epistemic paradigms. Whelan studies endometriosis patients’ ‘pragmatic model for knowing’, incorporating scientific as well as experiential claims in ways that can reinforce existing epistemic hierarchies.²⁴ Similarly, complementary and alternative medicine communities both resist and align with established epistemic hierarchies.²⁵

There appears to be some consensus, therefore, that recent UK health activism has been characterised by the promotion and insertion of ‘lay knowledge and experience’²⁶ into matrices of health governance and knowledge production.²⁷ This demands increased attention to various publics not as passive consumers of scientific claims but as generators of knowledge and arbiters of the validity of knowledge. This has prompted renewed efforts to take broader ‘cultural’ analyses of health movements more seriously. Brown et al., for example, claim to successfully ‘synthesise’ cultural perspectives on social movements with the functionalist and rationalist accounts of early Tilly, McAdam, and Tallow,²⁸ echoing a similar move attempted by McAdam himself (with others).²⁹

There remain, however, puzzles in how the ‘cultural’ is conceptualised within these literatures. The term itself is seldom defined. Where utilised, it is often as a tweak to dominant rationalist understandings of social movement behaviour, where movements mobilise cultural resources in light of emergent political opportunity in pursuit of pre-set objectives: ‘Rational Choice +’. Relatedly, where cultural renderings do take centre stage, culture is often portrayed as a set of pre-existing resources to be wielded. A question commonly posed, therefore, is ‘how do movements use cultural resources’ to achieve their goals?³⁰ Such accounts are somewhat instrumentalist regarding the strategic ‘framing’ of culture,³¹ in ways akin to more material resources. Lastly, and most crucially, as culture is reified and objectified ‘out there’: social activists’ actions are not themselves understood to be constitutive of culture.³² More recent developments in social movement theory have sought to attend to cultural embeddedness more forcefully. Armstrong and Bernstein break with the established ‘polity model’ to argue for culture as a central, constitutive force;³³ that institutions are both material and symbolic; and that the material and symbolic are, as the introduction to this volume asserts, completely intertwined.³⁴

In this chapter we draw on these understandings of health activism to explore how health activists shape and constitute cultural meanings of the NHS within hospital campaigns. What work must they undertake, and what are the epistemic dimensions of this work? In the case of potential hospital closure, how are hospital sites ‘culturally encoded’, and what forms of knowledge are articulated in this process?³⁵

Study design and method

This chapter is based on an analysis of a selection of interview data collected from two studies of public involvement in hospital change and closures in the NHS.

• Study 1 was conducted between 2014 and 2018. It involved case studies of four hospital change proposals in Scotland in the 2010s, with interviews conducted by author 1 and author 2. The study design and method are reported more fully in other publications.³⁶ This chapter explores data from interviews with active campaigners in the case study closures.
• Study 2 was conducted between 2016 and 2017, and explored policy on public involvement in contentious service change in the NHS. It was more focused on policy than on local practice, but incorporated a small number of interviews with campaigners who had opposed proposals in England, Northern Ireland, Scotland, and Wales, conducted by authors 1 and 3. This chapter explores data from these interviews. The study is more fully reported elsewhere, including detailed online supplementary information.³⁷

The subset of interviews that we draw on here were all conducted by authors 1 to 3, using a closely related semi-structured interview schedule. These were among the longest and richest interviews in both studies, and the transcripts are a fascinating record of people’s passionate engagement with the future of their local hospitals. Both studies received ethical approval from University of Edinburgh Usher Institute Research Ethics Group. In keeping with the requirements of anonymity, quotations have been anonymised, pseudonyms allocated, and identifying information removed from quotations below.

Because of the different sizes of the two studies, the sample of hospital campaigners is weighted towards interviewees located in Scotland, with four in Wales and only one in each of England and Northern Ireland. While there are significant, currently growing differences between organisational structures in the respective NHSs, which meant that campaigners faced different bureaucratic processes of NHS decision-making and consultation,³⁸ there were many consistencies, and some alternative dimensions of difference, in campaign tactics across the cases. As in Crane’s chapter in this volume, the sample of hospital campaigners includes above-average proportions of retired people and of people currently or previously (before retirement) employed by the NHS. The balance of men and women within the sample was fairly even (see Table 4.1).

For the purposes of this chapter, authors 1 and 2 conducted a thematic analysis of the anonymised transcripts. Our approach to analysis is based on the Framework method:³⁹ we constructed a provisional coding structure which we then revisited more inductively as the analysis progressed. All names used in the chapter are pseudonyms.

Findings

Community as resistance is the dominant cultural face of hospital closure, made most manifest through protests, placards, and petitions. In interviews, campaigners described multiple functions of such visible oppositional tactics. Such actions both forge publics and make them visible as credible and legitimate democratic bodies. These actions similarly identify and publicise political adversaries and potential allies – be they ministers, managers, or civil servants. Our active campaigners underscored the public symbolism and indeed political weight of this kind of labour:

These publicly orientated actions are familiar from media coverage, but the degree of strategic planning around them is rarely evident from the end product of news reports. Campaigners also reflected on past protest events and often saw them as pivotal moments.

Additionally, though, interviewees described the way in which assembling a visible oppositional public both effected change and galvanised their own belief in the importance of their mission.

Mobilisational work in communities was thus described as doubly valuable, convincing both ‘the opposition’ and campaigners themselves about strength of feeling.

Nevertheless, while such publicly visible actions were clearly important, our interviews with active campaigners described the bulk of their labours within more subtle forms of ‘knowledge’ work, often running more smoothly with the institutional grain. Newman defines knowledge work in rather more agonistic terms, whereby the aim is to challenge ‘dominant hierarchies of knowledge and expertise in order to transform patterns of dominance and exclusion’.⁴⁰ Our hospital campaigners, though, were often more reformist than transformative, making pragmatic choices about when to challenge or align with established, or ‘credentialed’, knowledge.⁴¹ Credentialed knowledge was interwoven with more ‘oppositional’ lay knowledge and expertise, but in direct dialogue with managerial and clinical claims.

The centrality of patient experience to campaigns varied across the different hospitals. In the case of the Complementary and Alternative Medicine (CAM) hospital, operating at the very fringes of mainstream healthcare, the insertion of lay knowledge and experience into debates around healthcare provision appeared the most pronounced.⁴² One prominent campaigner saw their role as being ‘to speak, and to say how it was’ (Susan), adding, ‘I tended to just rely on the actual, trying to portray the experience of being a patient.’ In this way, they were indeed directly challenging dominant, organisational rationalities ‘from above’:

In other campaigns, interviewees described the importance of contributing patient experience via NHS-approved platforms:

Here, ‘stories’ of experience from a range of people not immediately associated with the campaign are seen as having a particular value. Such stories obviously translated easily and directly into outward-facing campaigning and media work. The more consequential endeavour, however, for campaigners was in ‘fixing’ such knowledge via public portals (as in the Patient Opinion example above) or in other official and quasi-official documents that could inform decision-making:

While this was a particularly pronounced case of such knowledge work, we identified similar work in different forms across many of the campaigns. It effectively bridges experiential and credentialled forms of knowledge, as the next quotation suggests, by introducing a criterion of authenticity:

One campaigner in the case of the CAM hospital, where the promotion of experiential knowledge was central to the campaign, also drew on more credentialed forms of knowledge in order to locate and validate his own experiential understanding:

This campaigner then reflected on the additional translation work to bring such evidence to decision-makers. The CAM patient campaigners later reported success in inserting their experiential knowledge of hospital care into crucial board papers considering the facility’s downgrading, so that the final papers better reflected ‘what the unit did’ (Lisa). In this way, the campaigners were in effect producing official representations of the hospital, with material as well as symbolic consequences.

In another case of a prospective community hospital closure in rural Scotland, two lead campaigners assumed an institutionally versed approach to their advocacy, leveraging legal, policy, and local politics instruments at different levels of the system. The insertion of experiential knowledge of the hospital and its model of care was less prominent in their strategising. Their wrangling with the local council, regional NHS, and Members of Parliament was in some respects strongly ‘institutional’, making reference to higher authorities including human rights and equalities legislation. Moreover, at least on the lead campaigner’s accounts, their knowledge and understanding of the detail was superior to that of the local community council, assuming a position of strength and authority over other community representatives who in their view lacked the ‘skill set’ (David). These members, on this account, were not system-literate enough, a stance rather removed from challenging dominant epistemic hierarchies. In one framing, the lead campaigner reiterated:

These campaigners primarily directed their opposition to the local management of the ‘NHS’ itself. This seemingly encompassed the board and clinical staff but also perceived faceless bureaucrats and managers making, according to their account, unaccountable and non-transparent decisions. Part of the campaigners’ efforts, therefore, was to re-insert ‘politics’ into decisions that had been deliberately depoliticised through bureaucratic process and anonymity:

For this campaign, therefore, the NHS was symptomatic of a growing democratic deficit in British institutions but also of a now entrenched managerialism that was unable to uphold British (or Scottish) political and cultural values more broadly. Indeed, the NHS management of the hospital had, the campaigner felt, erased its antecedent cultural value over time:

This emphasises that, as Gosling has noted,⁴⁴ the 1948 creation of the NHS is merely one event in the histories of older hospitals and their relationship with their communities. This monolithic portrayal of the NHS as threat to local culture was unusual among our cases. In another, highly politicised proposed closure, campaigners instead described themselves as deeply embedded within local networks of NHS expertise, clinical knowledge, and above all values in opposition to ‘the government’ of the day. They emphasised the strength and objectivity of ‘their’ clinicians’ arguments in shared response to the proposed changes: the epitome of credentialed knowledge:

This evidence, and the judicial review it informed, were in this campaign about ‘reclaiming power’ (Linda) from national politics, resonating with Newman’s agonistic conception of knowledge work.⁴⁵ This closely resembled the words of a campaigner from a different hospital, who reiterated:

Here, credentialed sources of knowledge produced by experts within trustworthy and credible public institutions like the NHS not only have weight but provide the final bastion against politically driven assaults on knowledge, ‘truth’, and evidence production. At the same time, such strongly credentialed knowledge was democratised and given meaning by its experiential ‘connection’ to the people to whom the NHS ‘belongs’ (Linda). Through this epistemic labour, clinical and public campaigners re-inscribed the NHS as both an authoritative and public institution, to symbolic and ultimately material effect.

Questions of ownership also loomed large in other cases, especially where the hospitals under threat were small community facilities.⁴⁶ In one such case, campaigners again emphasised the (pre-NHS) history of their hospital, which had been funded as a community war memorial in the aftermath of the First World War. In this quotation, the campaigner highlights how the history of the hospital, at the heart of the community, was inscribed and re-inscribed by cultural rituals of remembering:

At the same time, in some cases that local ownership could extend beyond the material structure to include the maintenance and even expansion of the hospital as a broader assemblage of care. In the same case study, community fundraising and volunteering had enabled the development of tailored services as an extension of, or even challenge to, established NHS care:

This performance of community ownership was thus perennially at the mercy of wider NHS trends: ‘Sometimes NHS wanted to sort of centralise things, sometimes there was more favour, it seemed more favourable to have sort of local services and things’ (Karen). The ongoing defence of the hospital, therefore, involved a degree of translation and indeed negotiation between campaigners’ visions and those of local managers. In this case, the ‘space’ and opportunity for the public shaping of ‘their’ NHS was visible to campaigners, in response to shifts in the politico-cultural climate:

In another rural hospital (providing acute care), campaigners claimed principles of localism, access, and equity, this time in the face of a remote, bureaucratic rendering of the NHS:

This (one-time) campaigner previously advocated successfully for new, credible evidence generation (in collaboration with a local university) on models of delivering rural services, but also to re-establish public trust: ‘part of the evidence base needs to be the sort of contract between the people and the deliverers’. In the face of such mistrust of healthcare reconfiguration over time, the importance and symbolism of retaining and defending local hospitals only intensifies:

This was a reasonably unusual example within the wider studies, concerned with changing and defending the care model rather than simply supplementing and improving patient experience. One hospital included a community-run gardening project for patients with dementia, which had changed the physical structure of the hospital with ramps and an accessible toilet, to enable as many people to enjoy the space as possible. Even here, though, it was noticeable that this voluntaristic engagement with the hospital had material consequences for the facility, and also enacted an everyday sense of belonging that countered sudden top-down managerial efforts at change.

Conclusion

The predominant vision of public responses to hospital closures in the UK’s cultural imaginary has been one of resistance, epitomised through media coverage of campaigns. In other published work, Stewart has argued that this starting point, evident as far back as the debate around Powell’s hospital plan,⁴⁷ has also set the agenda for significant academic scholarship around the topic.⁴⁸ While this may capture the mobilisational function of protests, it is only one snapshot of wider ongoing social processes. Indeed, in one of our cases it was suggested that such photographic opportunities were stage-managed by political parties with no connection to the primary ongoing campaign. Perhaps because they have been approached primarily as a policy problem to resolve, scholarship on hospital campaigns has rarely engaged with wider sociological or historical literature on health activism, where epistemic and cultural aspects of activism have been to the fore.

This chapter has reported some of the complex work that sits around, shapes, and feeds off those photogenic moments of mobilisation in contemporary hospital campaigns. This includes strategic decisions about when and how to organise visible public protests, as an alternative or supplement to ‘behind-the-scenes’ influencing. Some of the campaigns we studied involved subtle mobilisations of positive patient experience within the hospitals, while others translated this into more formal, population-level arguments that mimicked the ‘official’ credentialed knowledge of the state, appealing to sources of authority beyond local NHS decision-makers.

Finally, we argue that this activism frequently starts before and goes beyond reacting to NHS change proposals, rooted in productive long-term relationships with NHS hospitals that have (and are given) cultural meaning. Our argument is that both in their public campaigning work and in the behind-the-scenes efforts to influence decision-making, campaigners are not merely leveraging or seeking to change extant cultural representations of what an NHS hospital should be. Rather, campaigns, and societal understandings of the ‘good’ hospital, are recursively produced. In this, the distinctions between national and local which Crane has described are intriguing.⁴⁹ At times local campaigns present their work as ‘saving the NHS’, and in other instances ‘the NHS’ is presented as a faceless threat to distinctive local hospitals. This distinction, between local material realities and national symbol, is a recurrent theme of the current volume.

Contemporary healthcare is, of course, less firmly embedded in hospitals as physical buildings – as Whitecross’s chapter in this volume explores⁵⁰ – and it may be that the defence of buildings loses its centrality in future UK health politics. However, attending to the epistemic, mobilisational, and voluntaristic work of hospital campaigns can redress the reliance of NHS scholarship which is orientated around documenting and evaluating the state’s decisions: through policy documents and newspaper coverage especially. This mirrors the work of social movement scholars who have critiqued a ‘political process’ model of social movements for being excessively state-focused, dismissive of non-instrumental tactics, and slow to acknowledge the activism of ‘non-marginalised’ populations within campaigns. Alternative ‘multi-institutional’ models argue that social movements have their own dynamics and purposes, in which the material and the symbolic are intertwined.⁵¹ This enlivens a culturally attuned account of the NHS by decentring the notion of the NHS as singular institution located only or primarily within the political-administrative bodies of the state. Hospital campaigns often include fundamental contention about the NHS, conducted by actors including politicians, managers, clinicians, patient groups, and other publics including geographically bounded communities. At stake in these processes is the future of a particular hospital, but also always and more fundamentally, how society should make its commitment to universal healthcare meaningful. The richness of qualitative data and sociological analysis can provide a valuable complement to these questions of meaning and belief, enhancing and challenging the cultural histories that this collection addresses.